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Monthly Archives: April 2007

Just got back from my 6, er, 9.5 hour EMS (emergency medical service) shift (my medical school has a unique program that sends first year medical students to ride with paramedics to pick up emergency calls). I’m not going to go into much detail tonight (because my shift started at 6pm, and now it’s 4 AM), but I just wanted to mention: I have lots of respect and love for EMTs and parademics now. Briefly, some lessons I’ve learned tonight:

1. When there’s an ambulance truck behind you, GET OUT OF THE WAY! Even if they don’t have their siren on, the truck may be transporting a patient; they might just be taking it slow(er) so as not to cause too much pain to the patient. Nonetheless, that person needs to get to the hospital ASAP. One patient tonight had an post-surgery infection, and boy, did we get an earful each time the truck went over a bump.

2. Don’t be the boy that cried 9-1-1. Twice tonight we received false calls: one from a caller who then disconnected his/her phone line (i.e. prank call, but may have been associated with a mental illness), and another from someone pressing the wrong button on the house alarm. Sometimes there’s not a lot going on, but sometimes there is: EMS is a limited resource, and it’s not cool to waste it. Then again, if you’re sick or in serious pain, use it (because it’s better to be safe than sorry).

3. One thing that never really seemed concrete to me before tonight was the notion that EMS really prepares patients for hospital care. Although doctors and nurses have a much more complicated job regarding diagnosis and treatment, EMS does the initial stabilization of the patient’s condition during the first crucial hour of an acute crisis. Furthermore, while doctors and nurses might subconsciously expect patients to be served up on a silver platter (i.e. presented in a particular, uniform fashion), EMS deals with a very wide variety of situations. What I saw tonight was pretty mild: light blood, projectile vomit (i.e. fountain), diarrhea, nudity, stab wound.

4. With only a few exceptions, I think that paramedics and EMTs are the health care providers that bear witness to the most pain. They’re the first to see trauma, and they’re also the ones who see people in pain before they are sedated or calmed down within the hospital environment. Of the several calls we received, three of the four in which we brought patients back to the hospital were patients in excruciating pain. They weren’t just screaming for attention: you could tell that they were in really, really bad pain. By contrast, and I could be wrong, but I’m under the impression that most doctors and nurses don’t have to deal with as much pain because the patients they see have already been administered analgesics (pain killers), will rapidly be administered pain killers, or they only see individual patients for a few minutes at a time. Some might work with patients in a lot of pain all the time. But they have the ability to leave the room. However, for me and the two paramedics, we had to work with the screaming, pained patients for half an hour or more at a time (moving the patients from their houses to the ambulance truck, riding to the hospital, and then escorting them from the truck through the check-in process and eventually to a hospital bed).

5. People need health insurance. Otherwise, a lot of hospital Emergency Departments simply won’t take the patient seriously. The paramedics and I waited one hour and forty-five minutes with one uninsured patient on the stretcher, just inside the entrance of the ED, while the staff was “trying to find a bed.” This also meant that my team and I missed all of the trauma calls during our shift because of having to wait at this ED next to the stretcher. Another patient came in with another EMS crew half an hour after we arrived, and they immediately received a bed. Our guy was in serious pain, but he was a trooper and tried his best not to cry out. He eventually got a bed, but to me, it seemed clear that the nurses and the doctors weren’t going to go out of their way to take care of this particular patient. Of course, it was late at night, and they were probably all tired. But they definitely shuffled a lot faster for the other incoming patients. It doesn’t surprise me, especially since there is so much more incentive for taking care of paying patients.

6. Like many aspects of this early stage in my medical training, this was a very humbling experience. Even though I’m very happy and confident because of my good bedside manner, decent history-taking, growing ability to do a (decent) Tier One physical exam, and my early proficiency with IV cannuli and laryngoscopes, there are vast realms of medicine in which I have little knowledge or experience. One of these is Emergency Medicine: one Fast Track shift and one long EMS shift later, I still don’t quite get it. By that, I mean I don’t think my personality and approach fit it well. Maybe I just need more experience in this field to get my finger on the pulse, but I think I probably work better with the unknown in a more stable setting (outpatient?) or with more extensive background information and greater complexity in the challenge at hand (intensive care?). It gives me more respect for ED docs like shadowfax and Panda Bear who probably do enjoy the fresh unknown of incoming emergent patients. Either way, as I was standing there next to the patient my team brought into the ED for more than an hour, I really wished that I had enough expertise and knowledge to help him right then and there (since no one else was bothering to).

“… had I known how to save a life.”

While I personally believe that the federal government needs to play an important role in the promotion and establishment of universal health care (that is, facilitating and making sure that everyone has health care coverage, but not necessarily paying for everyone as a single payer), I am amazed by the many instances in which government officials have severely damaged the practice of medicine in the U.S during the Bush Administration. I will mention just a handful that particularly bother me at this time due to their blatant impositions of government authority in medical decisions.

The Current Issue: Partial-Birth Abortion

On April 18, 2007, the Supreme Court upheld the 2003 Partial-Birth Abortion Act in the court case Gonzales vs. Carhart that bans D&X, the safest procedure used in second-trimester abortions. Previously, the 8th Circuit Court of Appeals ruled in favor of partial-birth abortion, until Attorney General Alberto Gonzales appealed the decision and brought it in front of the Supreme Court. The 2003 act was pushed through Congress through the leadership of Senator Bill Frist.

The ruling by the Supreme Court “allows” D&X to be used in cases where the mother’s life is “in imminent danger,” but for no other reason, including in cases where the pregnancy is just “threatening her health.” A series of editorials in this week’s New England Journal of Medicine strongly question this decision, particularly since there is no specification of what degree of mortal risk permits the procedure. The Supreme Court ruling endangers physicians who are involved in reproductive health by further exposing them to prosecution based on an act with vague definitions of what is permissible, what isn’t permissible, and when and where the act applies. Editor-in-Chief Jeffrey Drazen, M.D., asserts that the Judicial branch has joined the Legislative Branch in trying to “practice medicine without a license,” owing to the interference in medical decisions by both branches of government at the expense of the health of patients.

The act states:

(1) A moral, medical, and ethical consensus exists that the practice of performing a partial-birth abortion — an abortion in which a physician delivers an unborn child’s body until only the head remains inside the womb, punctures the back of the child’s skull with a sharp instrument, and sucks the child’s brains out before completing delivery of the dead infant — is a gruesome and inhumane procedure that is never medically necessary and should be prohibited.

(2) Rather than being an abortion procedure that is embraced by the medical community, particularly among physicians who routinely perform other abortion procedures, partial-birth abortion remains a disfavored procedure that is not only unnecessary to preserve the health of the mother, but in fact poses serious risks to the long-term health of women and in some circumstances, their lives. As a result, at least 27 States banned the procedure as did the United States Congress which voted to ban the procedure during the 104th, 105th, and 106th Congresses.

and furthermore:

An abortion in which the person performing the abortion, deliberately and intentionally vaginally delivers a living fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother, for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act, other than completion of delivery, that kills the partially delivered living fetus.

The Key Players:

Shameful and Knowing It

1. U.S. Attorney General Alberto Gonzales

That Gonzales has taken on the cause of fighting abortion rights signifies his departure from his prior personal convictions in order to serve as one of President Bush’s many yes-men. He, in fact, was perceived as being in favor of abortion rights, a notion that drew opposition from Republicans prior to his appointment. His term as Attorney General, however, has thus far been marked by conduct consistent with the often inconsistent, incompetent and undeniably frustrating manner exhibited by many Bush appointees. For example, during his testimony in front of Congress on April 19 about the questionable dismissal of eight U.S. attorneys, he stated 71 times in response to questions that he had no memory regarding events surrounding the dismissals. On another occasion, he stated in front of the Senate Judiciary Committee that the U.S Constitution does not guarantee habeas corpus, a statement that was immediately questioned by Senator Arlen Specter.

2. Senator Bill Frist, M.D.

More disturbing on this topic is the conduct of Senator Frist, not only in pushing forth the Partial-Birth Abortion Act of 2003 (as representing the “consensus” of moral, medical, and ethical opinion) but also in his conduct as a representative of the medical communty with Congress. As a physician and the Senate Majority Leader, Senator Frist played a very influential and controversial role as the voice of the American medical community within the Legislative branch of the federal government. However, on numerous occasions, he misled Congress. The most public and obvious of these was in the case of Terri Shiavo, a woman who was in a persistent vegetative state. Dr. Frist, after viewing a home video from Shiavo’s parents (who wanted to keep her on life support indefinitely, unlike her husband, who petitioned to a Florida court to determine whether or not she would have wanted to have life support removed) stated in a speech to Congress that he did not think she was in a persistent vegetative state (a state, unlike coma, from which there is virtually no possibility of recovering consciousness). Although the Florida 6th Circuit court determined that there was convincing evidence from numerous statements and accounts from people close to Shiavo that she would want to have life support removed, Governor Jeb Bush and Congress swooped in to stop the removal of life support. The Republican-led Congress went so far as to subpoena Terri Shiavo and her husband to testify in front of Congress, noting that her inability to do anything would mean that she would be held in contempt of Congress and this would effectively block any attempts to remove her feeding tube.

shiavo.jpeg

This is a CT Scan, the left showing a normal 25-year-old’s brain and the right showing Shiavo’s brain in 2002, three years before she was allowed to die. Now, a neurologist, or even a first year medical student, could tell that someone cannot recover consciousness with that extent of damage to the cerebral cortex. There simply aren’t enough neurons there. Despite this, Dr. Frist compromised his integrity as a physician by disputing the assessment of the Shiavo’s neurologists and effectively asserting to Congress that Shiavo had a chance of regaining consciousness and should not be taken off life support. Not to mention that Dr. Frist is a cardiothoracic surgeon. Now, specialist physicians do have knowledge outside their own specialties, but typically, it’s worth deferring to the opinion of a specialist in the field in question (i.e. the neurologist for neurological issues).

Dr. Frist doesn’t represent the medical community, and if anything, seems to have done a disservice to medicine and patients. While he may have been an excellent physician prior to his political career, it seems that he has taken considerable measures toward rejecting the professional integrity with which physicians are supposed to conduct themselves in order to further his political career. This is quite unfortunate, because his example will undoubtedly discourage other more credible physicians from pursuing political careers with ideal aims.

Strong Enough to Brave the Fire

Dr. LeRoy Carhart – I know nothing about this man, except that he is a practicing physician who has taken a stand on a highly-charged, political issue with profound impact on his practice of medicine. Dr. Carhart is one of three abortion providers in the state of Nebraska, and he challenged the 2003 Partial-Birth Abortion ban in the U.S. 8th Circuit Court of Appeals. Like many abortion providers, he has been the target of violence: at least on one occasion, arsonists (presumably anti-abortion activists) set fire to his house and farm, killing pets and livestock and destroying much property.

Nonetheless, he is still pursuing this cause: not out of financial profit or because he hates babies, but probably because he believes that there are real-life situations where mothers must choose abortion in order to avoid serious risks to their health (not just lethal risks). After all, how can one expect a mother to be able to take care of her child if she is severely debilitated by the pregnancy? Would the child, looking back at the situation after birth, even have wanted to be born under those conditions? These risks to health may not be apparent until the second trimester, and the risk to life may not fully develop until after the second trimester. What then? The Supreme Court and Congress have just given this woman a death sentence – or the physician a prison term for trying to save her life.

I have profound respect for abortion providers. No doctor delights in killing. But good doctors do uphold the wishes of their patients that correspond with improvements in happiness and health, even if it means ending life. One major change in the provision of end-of-life care is the emphasis on patient autonomy: if a patient would die without life support and expresses that desire (himself/herself, through a power of attorney or living will, or if sufficient evidence is demonstrated of that desire), then physicians must allow the patient to die rather than needlessly take heroic measures to keep him/her alive. In a way, this is exactly what Congress and the Supreme Court have done during the Bush administration: take heroic measures to preserve life, at the expense of the wishes of the patients.

Concluding Thoughts

My political views tend toward the liberal, but my approach tends to be more moderate. I listen to both conservative and liberal views, as there is wisdom to gain from all sides and progress to be made in the space between. However, several changes to medical practice enforced by Bush administration-led entities have constituted serious breaches into the doctor-patient relationship and the ability of doctors to provide services to patients. Unless the medical community and its allies inside and outside government take a stand, this trend may just get worse. My hope is that future presidential administrations have more foresight and respect for patients, particularly women. This administration has, through its appointments in the Supreme Court and the FDA and through Congress, shown contempt for both women and the autonomy and authority of physicians in medical decision-making. If we know any better, we won’t let this happen again.

Lately, I’ve been reading more and more medical blogs, and it has been interesting reading that of an Emergency Medicine resident who comments at length about health care coverage. While I sometimes find his writing to be dramaticized and overly cathartic (as amusingly demonstrated by both his comment thread fans and his passionate critics), he tends toward intelligent commentary and analysis of the push for universal health care. Furthermore, his stance is decidedly conservative, and I would likely find my future pursuits to only appeal to half of this country if I didn’t at least occasionally listen to perspectives such as his.

I’m still trying to figure out my own perspectives on what universal health care would ultimately mean for the U.S., and how it would best be implemented. While I don’t necessarily believe in single-payer systems, I do think that charity-based “safety net” health care should eventually be phased out (albeit at different rates for each region): New Orleans is the perfect example of a city that currently needs a safety net, but can benefit from setting a timeline toward mandate-based policies requiring and facilitating health insurance ownership/coverage for all citizens (as currently in the process of being implemented in Massachusetts, which is the plan Secretary Leavitt is trying to force on Louisiana at a time when it might not be feasible – the verdict is still out).

On the one hand, there is the notion that we need to reduce health care costs. This is reasonable, but it is based on faulty interpretations. It is commonly cited that the U.S. spends more than any other country on health care, but it doesn’t have the best outcomes or population statistics (life expectancy, infant mortality, etc.). This is partly due to health care inequalities (the life expectancy for one community of East Asian women in New Jersey is 80+, while the life expectancy of Native American men in another community in North Dakota is around 55). This is also due to the large investments that the U.S. places on discovery: research and development of new treatments and medical technology (of which the U.S. produces more than any other country). Furthermore, Americans (who do pay for health care) pay for convenience and excellence: we pay for shorter waiting times (minutes or hours for tests, imaging studies, and procedures instead of days or months), and we also pay for the most highly trained physicians (high profiles figures in other countries are often sent to the U.S. for acute medical conditions). Lastly, the U.S. is a big, heterogenous country: in some ways, it’s like 50 smaller countries. Health care, depending on your measurement and subjective perspective, can vary considerably from state to state.

On the other hand, there is some compulsion toward “providing” health care for all American citizens. Some say it’s a right and criticize our willingness to propagate health care disparities that uphold socioeconomic disparities. Others point to the swelling of Emergency Departments with uninsured patients and the notion that these patients drive up costs for everyone else. Others argue that a penny in prevention saves a hundred dollars in later acute care. Others (me) suggest that people aren’t nearly as productive toward society when they’re sick and disabled as they could be when they’re more healthy. These are just a few reasons – there are probably more I’m forgetting to mention.

It seems that things aren’t going to get any better if we do nothing. However, if we push for some rendition of universal health care, we have to do it in a way that actually solves problems. Panda Bear points out in his comment thread that improving access doesn’t necessarily result in better health, especially since improved access doesn’t equate with improved usage of health care resources. I completely agree. However, this information is weak support (at best) for the argument that primary care for the poor and uninsured is a lost cause.

Where I disagree is in the assumption that people cannot make the right decision (because they currently aren’t making the decisions to improve their own health statuses). My thoughts on this issue coalesced (in my post-exam, semi-cogent state) when I read shadowfax’s criticism of Panda Bear’s reference to poor people as “people who don’t think and plan ahead.” It is often stated (usually by conservatives) that people make bad choices, and accordingly, we shouldn’t go out of our way to help them. Instead, it is argued that we should only help those who help themselves (assuming that we, the doctors, are in the right position to judge this). What sense does it make to applaud people who can afford health care when they choose to seek health care and criticize people who can’t afford it when they choose not to seek care? That is the current state of affairs. Now, if everyone were hypothetically covered by health insurance, would it make any more sense to criticize those people who still aren’t seeking primary health care?

My argument: no, that does not make sense. Why? People make decisions based on varying degrees of acquired information, and information disparities are considerable. One example is with smoking. Everyone knows that smoking is bad for you, but they don’t know why. Most people think that smoking leads to lung cancer, but this is only one effect: tobacco use also dramatically increases the risk of heart attacks and strokes. Furthermore, people say, “I’m going to die of something anyways.” What they don’t realize is how much pain and suffering they might have before they die, or how prematurely they may die. Pain and suffering from: not being able to breathe, gangrene, blindness, pain and lack of physical mobility due to heart failure, not being able to sleep well because of fluid in your lungs, losing mental and motor faculties because of a stroke, etc. Sure, everyone dies: but who dies in their forties and fifties these days? Who wants to spend the last decades of their life trying to sleep with three pillows tucked behind their backs because they feeling like they’re drowning when they lie down?

The CDC/U.S. Department of Health and Human Service’s “Chartbook on Trends in the Health of Americans” shows extensive data indicating that increased years of education correlate with reduced prevalance of smoking. In 2004, 29.1% of people who didn’t graduate from high school or get a GED smoked, 25.8% of those who did graduate, 21.4% with some college education, and only 10% of those who graduated from college smoked. While this correlation isn’t a proof of causation, it does suggest that people with access to more knowledge may have more accurate health knowledge on which to base their decisions. It’s a problem of value: some people don’t know the true value of health care they receive or preventive measures they might take. If they did, they might make the right choices (or try harder to, despite other obstacles such as financial costs, difficulty in finding resources, etc.).

I’d like to recall my story some months back about the young mother with her little girl that had a high fever and a bad cough. When I first saw her, the first thought on my mind was that she could be a typical, angry, impudent, noncompliant, charity patient with a tendency toward making bad decisions. However, that interpretation didn’t stick: it was completely wrong. The young mother had been waiting in the ER for almost eight hours; there were other places she needed to be. However, because she was worried about her girl, she came into the ER, foregoing a day’s worth of pay. However, as she waited for the chest x-ray, her doubts grew as to whether or not her daughter was really that sick. After all, it probably was just a bad cold, right? When the attending physician came to berate her for considering leaving AMA (Against Medical Advice), she obviously wasn’t happy. This physician was essentially accusing her of child abuse and putting her little girl in mortal danger. When the attending physician went away, she turned to me and showered me with questions. What is this medication for? What was the chest x-ray for? Why? She had no idea that pneumonia could be lethal: that up to 20% of untreated cases of pneumonia result in death. The doctors needed to determine whether her girl had pneumonia or acute bronchitis, but she had no idea why she was waiting for so long: if anyone had explained it to her, the message didn’t get across until she asked me. Was this privileged or complicated knowledge that I was passing along? No. But without it, she or someone else in a similar situation could have made a very bad decision. What if she didn’t even come in the next time? We might have a little girl with a fractured foot who might limp for the rest of her life. Or perhaps something worse. Either way, we might take the overly simplistic action of blaming the mother for making bad decisions. But we would be wrong.

Later this week, I’m going to be riding a six-hour shift in an ambulance truck with paramedics. This ambulance ride program is required for all first year medical students at my school. Though there is relatively little diagnostic expertise I can offer (at the most, I can do a Tier One physical examination and perform CPR), I plan to arm myself with what knowledge I do have available to me at this stage in my training that I might be able to pass on to others. The program director left us with the words you so often hear from the mouths of patients, parents, and family members in so many Emergency Rooms: “If only I had known.”

A skeptic might suggest that this is just an excuse; that people do know. However, this is the view of someone who blindly doesn’t understand why people don’t have the information they need. I have always been interested and acutely aware of deficits in knowledge, their effects on how much people can achieve, and what measures may be taken to amend this shortage of knowledge. Perhaps it may be worth it for me to make it a goal to make sure that “If only I had known” is a phrase that is never used again in the context of health care. At least, as it is used now.

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